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Division of HIV/AIDS Treatment and Care
National Center for AIDS/STD Control and Prevention
Dr Zhao Yan has no relevant conflicts of interest to report.
At the Virtual 2021 Conference on Retroviruses and Opportunistic Infections (CROI 2021), 2 speakers reviewed the impact of the COVID-19 pandemic on HIV treatment and on the delivery of healthcare services more generally. Another speaker reviewed contradictory data on the effect of HIV on COVID-19 susceptibility and severity. Here are my thoughts on those presentations.
Does HIV Affect COVID-19 Susceptibility or Severity?
At the beginning of the pandemic, people with HIV (PWH) were concerned that they might be more susceptible to SARS-CoV-2 infection or that they might be at risk of more severe outcomes upon infection. Initial observations did not find a higher proportion of PWH among hospitalized patients with COVID-19, and that observation has held over time. Since then, many observational studies on COVID-19 in PWH have been conducted that have had contradictory outcomes. A closer look at these studies shows that they varied widely in their designs, in the populations studied, in the control groups used, and in the adjustments for confounders. These differences may be responsible for the varying results.
A thorough analysis of recent research has answered several questions. First, PWH tend to be tested for SARS-CoV-2 at higher rates than people without HIV. High rates of testing are associated with access to healthcare, health-seeking behavior, severity of symptoms, and test availability. Second, in most unadjusted analyses, PWH seem to be at higher risk for SARS-CoV-2 infection than people without HIV. However, after the data have been adjusted for age, sex, and socioeconomic characteristics, little or no association is seen between HIV and SARS-CoV-2 infection. Numerous socioeconomic risk factors for SARS-CoV-2 infection are common among PWH, including racial or ethnic minority status, poor and crowded housing, residence in neighborhoods with high transmission, occupations requiring presence on site, congested transportation, multiple sex partners, and drug use.
Similarly, in unadjusted analyses, PWH appear to be at similar or higher risk of severe COVID-19 outcomes (hospitalization, ICU admission, and death) when compared with the general population. But, compared with the general population, PWH have a higher prevalence of hypertension, diabetes mellitus, chronic obstructive pulmonary disease, renal disease, and cancer, which are all risk factors for COVID-19 severity. More research is needed to determine whether HIV is an independent risk factor for poor COVID-19 outcomes. However, similar to the general population, risk for severe COVID-19 outcomes among PWH is largely a function of age and the presence of comorbid disorders.
Another observation that requires further study is the relatively lower rate of SARS-CoV-2 infection among PWH receiving ART regimens that include TDF/FTC, which has been seen in 3 separate studies.
The Impact of COVID-19 on the HIV Pandemic Worldwide
At the outset of the COVID-19 pandemic, researchers developed models to predict its possible effects on HIV diagnosis and treatment and to plan mitigation strategies. The models estimated the impact of COVID-19 containment measures, including lockdowns, travel restrictions, and physical distancing that could limit patient access to required services, as well as disruptions caused by the diversion of medical resources to COVID-19 treatment. Modeling studies estimated a 10% increase in deaths among PWH in low- and middle-income countries (LMICs) over 5 years. Interruption of antiretroviral treatment was the main cause of increased mortality in PWH. This suggested that maintaining continuity of services would be critical for PWH.
Emerging data reveal that COVID-19 mitigation has led to significant service disruptions throughout the world. In one global survey, more than 70% of respondents reported very high to moderate disruption in HIV service delivery. Another report from Eastern and Central Europe found only approximately 30% of clinics were working normally and serious concerns about drug procurement. Other global surveys found substantial reductions in HIV testing, HIV case identification, and treatment initiation in many LMICs during the first half of 2020. Decreases were also observed in treatment of pregnant women with HIV during the same period. By contrast, many of the LMICs were able to maintain the number of PWH in treatment.
Strategies to mitigate treatment disruptions that have been used successfully include telemedicine, toll-free hotlines, multimonth drug refills, community sample collection and community ART deliveries, home-based self-testing, workforce training, and use of social media to provide accurate information.
The Impact of COVID-19 Beyond HIV
The disruption of healthcare systems during the pandemic has had negative effects well beyond its impact on HIV treatment. During lockdowns, many patients have delayed treatment for other conditions, with poor outcomes. Reports from several countries showed significant decreases, of 30% and 40%, in patients presenting at hospitals with symptoms of myocardial infarction. The overall effects of the pandemic will be better understood after deaths from all causes in 2020 are compared with deaths in previous years to estimate excess mortality.
Previous outbreaks, such as the 2014 Ebola epidemic in West Africa and the 2003 SARS outbreak in Taiwan have been marked by significant declines in services. During the Ebola outbreak, antenatal care declined 22% and postnatal care 13% in Sierra Leone. Family planning interventions decreased 50% to 70% in Guinea. Care seeking declined due to fear of contracting the disease, distrust of the health system, and rumors about the source of the disease. In Taiwan, in 2003, ambulatory care decreased 23% and inpatient care decreased 35%.
A WHO survey of 105 countries covering March to June 2020 reported that 90% of countries experienced disruptions in health services. Emergency services were disrupted in 22% of countries, and urgent blood transfusions in 23%. LMICs were most affected.
The most commonly disrupted services were routine immunization, dental services, rehabilitation services, noncommunicable disease care, malaria campaigns, and family planning. The most common reasons for service disruptions were decreases in outpatients presenting for care (76%), cancellation of elective inpatient services (66%), deployment of staff to COVID-19 care (49%), and transportation lockdowns (48%).
The WHO has recommended that routine immunization continue, but mass vaccination campaigns could contribute to the spread of COVID-19. By May 2020, lockdown measures had blocked immunizations in at least 68 countries, putting 80 million individuals younger than 1 year of age at risk of contracting vaccine-preventable disease. Risk-to-benefit analyses suggest that the risk for death from COVID-19 is far smaller than the number of lives saved by routine immunization, suggesting that immunization should continue during the pandemic.
Lockdowns and other responses to the pandemic are also disrupting family planning services. As many as 47 million women in 114 LMIC have been projected to be unable to access modern contraceptives if lockdowns continue for an average of 6 months, resulting in 7 million unintended pregnancies. The reasons for disruptions are similar to those reported for vaccinations: redeployment of staff, fear of disease, lack of transportation.
Approaches for overcoming disruptions reported in the WHO survey included triaging to identify priorities (76%), replacing in-person visits with telemedicine (63%), task shifting (57%), novel supply chain or dispensing channels (54%), community outreach (53%), and redirecting patients to other facilities (52%).
What are your thoughts about the findings from these studies? I encourage you to answer the polling question and post your thoughts and questions in the discussion box.